FALLING THROUGH THE CRACKS: Executive Summary
The need for focused attention on births to low-income mothers in Hennepin and Ramsey counties is compelling. Within the state of Minnesota, slightly more than one-third (35.7%) of births occur in the metropolitan area represented by the counties of Hennepin and Ramsey . Yet, Hennepin and Ramsey account for over 43.5% of the states infant deaths annually, a disproportionate share compared to the number of births. Slightly less than one-third (30%) of all Minnesota births occur in the low-income population insured under the states Medicaid programs or MinnesotaCare . In Hennepin and Ramsey counties the percentage of newborns eligible to receive Medicaid during 1999 was 40%. This higher percentage of low income births is likely due to the combination of higher concentrations of poverty and higher birth rates among residents of Minneapolis and St. Paul .
Two infant mortality review projects conducted in the Twin Cities area in the 1990s concluded that a highly-fragmented perinatal service delivery system was a factor in many urban infant deaths. Reviewers from the two projects repeatedly identified the lack of comprehensive, coordinated support servicesabove and beyond the provision of basic medical careas a systems issue contributing to infant mortality. Comprehensive medical, social, and behavioral risk assessments, coupled with indicated support services,have long been recognized as essential components of high quality perinatal care. To provide such comprehensive services requires a coordinated approach and a barrier-free system with sufficient capacity (Brown, 1988).
While the two infant mortality review projects identified weaknesses and gaps in perinatal care coordination, they were not intended to document system-wide capacity. Therefore, in 1999, the Perinatal Survey Team was formed to examine perinatal care coordination and identify capacity issues in the metropolitan area. The vehicle chosen for this study was a qualitative survey, developed specifically for use in this research and administered to health care agencies and organizations serving Hennepin and Ramsey counties. The survey focused on the traditional safety netorganizations such as the community health centers and the public health nursing agencies. Health plans and hospitals were also surveyed. Because of limited funds,private obstetrical providers and private clinics were not included.
The goals of this study were: (1) to describe the existing baseline of perinatal care-coordination activities in Hennepin and Ramsey counties, and (2) to determine customary procedures, connections, and transactions between agencies/organizations delivering perinatal services. The target population was low-income persons living in Hennepin and Ramsey counties.
SUMMARY OF SURVEY FINDINGS
Survey respondents from community health centers reported that many factors have undermined their financial capacity and their ability to provide the comprehensive medical and social services needed by high-risk populations. Primarily, they commented on poor reimbursement rates, burdensome administrative tasks, heavy workloads for shrinking staff, and increased numbers of patients in need, especially those needing interpreter services.
Public health nursing agencies voiced similar concerns about the burdens of chasing reimbursements from multiple payors, the contradictory need to document medical necessity for home visits to address multiple and complex social needs that impact their clients' pregnancies, lagging technology, and the loss of their community connections. Most of their visits are to new mothers and babies rather than to pregnant women. Consequently, opportunities for prenatal preventive activities are missed.
Hospital responses revealed that some were unaware of how to connect to public health and community-based services that might be needed for follow-up after discharge of high risk postpartum mothers and newborns. Health plans surveys described maternity case managers who primarily coordinated services among providers and addressed patient needs by communicating with them by phone instead of in-person.
Overall, the survey found significant systems issues that may contribute to poor pregnancy outcomes in the two counties:
Health care and social service systems are fragmented by institutional, bureaucratic, and reimbursement barriers. While health plans, hospitals, community health centers, and public health nursing agencies all have admirable missions to provide quality perinatal services, all appear to lack the system integration necessary to meet the multiple and complex needs of high-risk families in Hennepin and Ramsey counties. For public health nursing and community health centers, the findings suggest system capacity is also lacking due to problems with funding, reimbursement, and lagging technology. Health plan findings suggest that they have capacity issues as well, especially in terms of their focus on using telephone contact for case management rather than face-to-face contact. While the telephonic case management model may serve important functions, the health plans descriptions of maternity case management did not meet the Survey Framework standard defined in this report. Particularly with respect to at-risk, low-income women, this model does not provide the necessary support, education, and advocacy needed to assure successful outcomes.
Communication between health care and social service systems is poor. Poor communication among health plans, community health centers, hospitals, and public health nursing contributes to fragmented care and services. While these organizations are represented on various collaboratives addressing maternal and child health issues, the working relationships necessary to address individual client needs are lacking.
Populations of color, American Indians, and refugees and immigrants are most heavily impacted. These populations are over-represented in the low-income population of Hennepin and Ramsey counties and, are therefore, most affected by gaps in the system. Recent demographic data indicate that these populations are growing in the urban area. If system problems are not addressed, existing racial and ethnic disparities in infant mortality and other poor birth outcomes are likely to persist and may even worsen.
In Hennepin and Ramsey counties,African American infants are 2 to 3 times more likely to die before their first birthday than white infants. American Indian infants are 3 to 4 times more likely to die before their first birthday than white infants. To address these disparities, local public health received federal funds and established Twin Cities Healthy Start. This program has developed community-based service networks providing coordinated care and improved communication for the African American and American Indian families they serve. But the program has confronted the difficulties of working effectively in an overall system that is fragmented and marked by institutional barriers.
Low-income women are not assured continuous health insurance throughout their childbearing years. Without continuous coverage there is no way to ensure access to primary health care, dental care, care for chronic conditions, family planning, preconception care, early pregnancy identification, and early and continuous prenatal care.
We must recognize that, in some large measure, problems with infant ill health are a legacy of womens ill health generally.
Wise, Paul (1993). Confronting Racial Disparities in Infant Mortality: Reconciling Science and Politics. Amer Journal of Prev Med Suppl. to Vol. 9:7-16.
Establish a Perinatal Work Group. The Minnesota Department of Health and local public health should work with the Department of Human Services, health plans and providers, social service and community-based organizations, and the Neighborhood Health Care Network to develop a perinatal care system that is adequately funded and that provides care coordination services shown to be effective in the research literature for socially at-risk pregnant women. The women impacted by this system should also be included in the Work Group.
Provide adequate and stable resources to rebuild system capacities of public health and community-based providers of comprehensive perinatal care coordination services.
Support Twin Cities Healthy Starts service networks. These networks are piloting a promising model of formalized, interdisciplinary communication and care coordination that are expected to reduce fragmentation of perinatal services to high-risk women.
Provide continuous health insurance to all women of childbearing age enabling them to have a medical home,primary preventive health care, family planning, preconception care, and early and continuous prenatal care.
1. There are 23,542 resident births in Hennepin and Ramsey counties
combined, with 65,953 total births statewide. Minnesota Center for Health Statistics,
2. Minnesota Department of Human Services, personal communication.
3. Minnesota Center for Health Statistics, MDH
Brown, S. (Ed.) (1988). Prenatal Care: Reaching Mothers, Reaching Infants. Washington,D. C.: Institute of Medicine,National Academy Press.
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